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Underweight and Underrepresented: The Cardiac Complications of Disordered Eating

We get it. Being overweight is bad for you. Extra weight strains the heart, forcing it to work harder, consequently raising your blood pressure and increasing your risk of myocardial infarction, cardiomyopathies, and stroke. Spending your days on the couch binge-watching Grey’s Anatomy probably isn’t the best lifestyle choice, and a diet of salty, trans-fat-fried carbohydrates cannot possibly be good for you. You do need some exercise to strengthen your heart, and fruits and vegetables are a nutritional necessity, but that’s common knowledge; we all know that already. So, let’s discuss something different; let’s discuss the other extreme–severe emaciation, caloric restriction, and compulsive purging. Underweights are underrepresented by/in the cardiovascular health community, and thusly, I have taken it upon myself to educate you on this equally unhealthy lifestyle.

Bradycardia and hypotension are the two most common cardiac complications of anorexia. In an endeavor to conserve energy, the body begins to shut down, slowing the heart rate and consequently lowering the blood pressure; neither matter is helped by nutritional irregularities/deficiencies (such as B-12, iron, magnesium). Both bradycardia and hypotension are generally benign, but prolonged cases of each can result in confusion, dizziness, fainting, fatigue, heart failure, and tissue death. Many bradycardic and hypotensive patients notice spikes in their heart rate and blood pressure when they stand up; some even experience palpitations, lightheadedness, and collapse. And that’s just standing–imagine what exercise can do!

Exercise in and of itself cannot cause a heart attack, but it can trigger one. The stress on your heart can induce palpitations, arrhythmias, arterial spasms, sudden cardiac death, and, yes, a heart attack. This exercise, while it should strengthen your heart, ends up weakening it because of the atrophic nature of muscles during starvation; you break down the muscle without giving it the energy it needs to build up again. Do I really need to tell you how dangerous this is?

This brings me to the second half of my post, the nutritional component. When deprived of nutrients, the body starts to eat itself. Contrary to popular belief (read: diet industry propaganda), fat is not the first thing to go; on account of their nutritional density, muscles are devoured, and the heart, as one of the largest muscles, is a natural victim. You can literally eat your heart out.

This catastrophic self-consumption leads to many dire results, including mitral valve prolapse, the flopping of the mitral valve, where its flaps collapse and allow for valvular leakage and regurgitation, eventually leading to arrhythmias, left ventricular enlargement, strokes, and heart attacks. Self-consumption is premised by malnutrition, an incredibly harmful state in its own right. A caloric deficit is also a nutritional deficit, since calories are not just energy, but couriers, carrying vital vitamins and minerals, including essential electrolytes. Electrolytes are necessary for heart function, as the heart’s de- and repolarisation is facilitated by ionic channels. A severe shortage of electrolytes can have immediate results like life-threatening cardiac arrhythmias; these, including the frequently fatal ventricular fibrillation, can cause cardiac arrest and, in rare instances (represent!), a heart attack. Consequences can be lasting as well, with electrolyte deficiencies yielding permanent extrasystoles (both atrial and ventricular, including various varieties of geminy) and Long QT Syndrome, the latter of which predisposes one to chaotic heartbeats, and in turn, heart attacks and/or cardiac arrests. It is also worth noting that heart attacks do permanent damage to the myocardial muscle, creating eventual and incurable cardiomyopathies.

Additionally, many underweight individuals are susceptible to vicious binge/purge cycles. A binge’s rapid influx of calories can cause systemic shock, manifesting as cardiac arrest, and self-induced emesis can do the same, with dehydration and the abrupt loss of electrolytes rendering similar effects. The cardiac complications of anorexia can be fatal, and if you are lucky enough to escape them, you are still susceptible to recovery-occurrent ones such as refeeding syndrome, a type of systemic shock analogous to that of a binge. Sounds fun, right?

Please do not do this to yourself. Maintain a healthy weight, eat a balanced diet, and exercise in moderation! Your body will thank you.

It Won’t Happen to Me

It won’t happen to me: That has been an overarching theme in and out of my recovery. I’m a smart girl; I did my reading. I knew anorexia had its consequences; I just refused to acknowledge them. Hair loss, muscle weakness, dry skin, fatigue, osteoporosis, amenorrhea, organ failure, death. Whatever. It wouldn’t happen to me.

It can. It would. It did.

Let me tell you about August 3rd, 2016: Light rain dribbled from the sky, and there was slight, dull ache in my chest. Thinking nothing of it, I got up, put on my favorite red lipstick, and popped three diet pills. My favorite scholar was lecturing on Shakespearean sexual suicides today, and I wanted to get to the hall early to tell him what I thought of Cleopatra’s death, how I read it as an extended enactment of the Renaissance ‘die pun’. I sped down the Selwyn stairs so quickly that I ran out of breath. It must’ve been the running that caused me to feel a little ill. No, I’d been sick earlier, too, right when I’d woken up. The pills, perhaps? A bout of violent vomiting truncated my contemplations.

The pain in my chest was worse now, heavier, and I was dizzy, so dizzy that the world spun around me and lights on passing cars danced like fireflies. It felt like someone was squeezing my left arm. I couldn’t breathe. I practically fell onto the ledge in front of the college, clutching at my chest with tingy, claw-like hands. A sensible passerby must’ve called the British equivalent of 911 (999?), because the next thing I remember was screeching down the rainy roads in a screaming ambulance.

I woke up–if that’s the right phrase?–with my face pressed into a green white tile floor. I turned my head a little to look around; I saw chairs, and couches, and a vending machine. There were legs, too, sneakers and swishing pants, voices and people, wheelchairs and carts. ‘Do you have an emergency contact?’ I heard someone say. Did I? Was she talking to me?

Hands grabbed my feet and my shoulders, sore, soared off the floor. I found myself sitting up, back against a bendy chair. I was confused. Why were we moving? Where we going, gliding and sliding, sliding and gliding? Or were we? Was I imagining this, dreaming, nightmare-ing? I tried to pinch myself, but my arm wouldn’t budge.

Wrinkled white paper crinkled underneath brittle bones as they dropped me into the hospital holding bed. Nurses–well, I assume they were nurses?– started sticking things on me, red and white circles with wild, winding wires. I could see a sea of them, all over me like some horrible kind of rash. I wondered what they were. No, I didn’t want to know; I didn’t want to have to know, if you know what I mean?

A woman in blue told me to stay very still. They were going to do an EKG now, and I had to stay very still. But what was an EKG? Would it hurt? Did they have to take any blood? Is that what the circles were for? Hadn’t my psychiatrist wanted me to get one of these a while ago? I had so many questions–and so little breath to ask them.

A whirring, a tapping, a scratching. The printer in the back of the room spat and choked, gagging on a scroll. There was a wrenching, ripping sound as someone broke it open, tearing out its contents. With furrowed caterpillar brows, the printer surgeon examined his specimen. He handed it to the woman in blue who nodded and left the room, muttering something about something called an echo.

‘Printer problem.’ Someone said, stomping on the sludgy silence.

‘Yeah.’ An awkward laugh, a sigh that filled the room. ‘Must be. This can’t be right. That wouldn’t happen to her.’

It can. It would. It did.

The woman in blue returned with cart. ‘We’re going to do an echo now’ she informed me, as if I had some clue what that was. Strangers stripped me, black scissors bisecting a brassiere back. Folds fell to the floor and like a ragdoll I flopped forwards, arms contorted backwards, purposefully pulled into a hospital gown. Cold hands nudged my shoulders into a sinking pillow, and suddenly something chilly crept across my chest. Blue goo, lots of it, glittered like snow drifts under a fluorescent sun, and a probe skated over me, making my heart beat loud, loud over the hospital beeps.

‘Okay.’ Voices whispered. ‘Okay.’ The word bounced off the whitewashed walls, fleeing the room, fleeing like a mouse trapped a hungry snake’s cage. ‘Okay.’ They all looked at each other; I could feel the fear in their eyes.

‘You tell her.’ They said, speaking all at once. ‘No you, no you.’

Tell me? Tell me what?

Doors slammed, footsteps hammered, and faces leaned towards mine. I saw a mouth move. A man said something, something no one should have to hear. ‘You suffered,’ he informed me, looking down at the stack of papers one more time. ‘You suffered an acute electrolyte-imbalance-induced myocardial infarction.’

‘I what? A what?’

‘You had a heart attack.’

‘A what?’

‘A heart attack.’

A heart attack? No, that was impossible. Only old, fat men had heart attacks. It wouldn’t happen to me.

It can. It would. It did.

I had a heart attack that day, and I’m glad I did. Yes, I’m glad I had a heart attack. It almost killed me, but it saved my life. It was a wake up call, a slap in the face, a red flag in the neverending haze. It forced me realize what I couldn’t on my own: I am not immortal; I am not invincible; I am not immune. It could happen to me–and it did.

Cake at a Funeral

I went to a funeral yesterday. I brought cake. It was a pink cake, pink with rainbow sprinkles. I had to take the elevator so I didn’t drop it. I set it down on the table when I got there–the little table, the rectangular table, the table with all the magazines. I had to leave it there while I payed–two hundred and forty dollars, as it sat there on the New England Journal of Medicine, two hundred and forty dollars, pink on the orange and the white. I felt the urge to write on it, that pang again; I even had my paper out, but I didn’t know what to say. The door opened, front and to the left. A head poked out, and a soft voice said “Hello”; you could barely hear her–her lips moved, but her voice was barely there, a cloud, a cumulus cotton candy cloud on the stagnant sugar-wind. I stood up; that was my cue. My flip-flops thwacked the carpet as I walked towards her, and I saw my cake soar past the rose-gold chairs, up, up under the aureate lights. 

She asked me “How are you?”

I handed her the cake. 

“Is that for me?”

I nodded.

“It’s very pretty.” 

I shrugged. 

“What kind of icing is that?”

“Vanilla. Vanilla with sprinkles.”

We reached the door. She stopped. I went in first. She closed the door. We both sat down. The chairs were brown. 

“How are you?” She asked again.

That’s when I began to cry. She wasn’t going to ask me that anymore.

“Are you okay?”

Silence settled like ashes in an urn.

“Do I have to go?” I asked her. 

“You don’t have to do anything.”

I curled up into a little ball, bringing my knees to my chest. She peered across the carpet, watching as I sobbed, watching as my tears rolled down onto my knees. 

“I heard your session with Adrien was hard.” 

“It was… It’s just…”

“I know.”

“You really can read minds.”

Smiles. Silence. Sobs.

“Thank you for the cake. It’s very festive.”

I looked up. Her eyes were such a pretty blue. “It’s a cake of mourning.” I informed her. 

She laughed. It wasn’t supposed to be funny. 

“I feel like I’m going to a funeral.” I told her. “Preparing for this appointment, I felt like I was going to a funeral.”

It was her turn to nod.

“It’s like… I just…”

“I know.”

“I feel like I’m losing a parent.” 

“Yeah.”

“But, like, an actual parent. Not like when my dad died, that didn’t matter, and my mom could die now for all I care.”

She didn’t judge. I could see the sadness in her eyes; I could see my sadness; I could see the care, the compassion there. There was no judgement; no, she didn’t judge; she just listened. 

“A parent I actually care about.”

“You’ve learned to care. You’ve learned to sit with your feelings.” She was right. Always.

“I just didn’t think I’d have to say goodbye. I just expected I’d quit treatment, die, or just not care…”

“But you do.”

“But I do.”

“Is it hard to say goodbye to me?”

“No.” I wiped my nose on my sleeve. The lie was so obvious that we both laughed.

“Do you think you’re never going to see me again?”

Another wave of tears, heavier this time, a downpour, torrential like an Austin August.

“From my side, I can still answer your emails, and you can call me anytime. If you’re ever in Austin, if you ever need anything, you can come and see me.” 

I looked out the window. A bird flew by. A bus drove down a hill.

“If I don’t hear from you for a while, I’ll have to close your chart. That just means that part of our treatment is over.”

“I’ll send you copies of my books when I publish them.” I said. 

“I’d like that.”

“And when I write a goodbye letter–which I will do–I’ll mail it to you.” 

“From London?”

“You’re probably disappointed I didn’t write one.” I said, avoiding the issue. “I meant to, but I didn’t know what to say.”

“That’s okay.”

“It’s not. Adrien and Vanessa both got one.”

“It’s okay.”

I wept. My tears hit the couch this time.

“When I heard you were moving to London, my first thought was that you were running, and then I thought maybe she’s ready.”

“Am I?”

“Only you can answer that.”

“But you know everything.”

She smiled. I memorized pattern on the tissue box–white with yellow diamonds, white with yellow diamonds and blue dots. 

“Do you need a prescription from me?” She asked finally. 

“I don’t know.”

“Can you fill it there?”

“I don’t know.”

“Can you get three months’ supply here?”

“I guess.”

“That gives you a little wiggle room, time to find someone in London.”

I didn’t want to find someone in London. “According to Google, all the psychiatrists in London are old white men who specialize in serial killers.” 

She laughed. I didn’t. 

“Seriously.”

“I’m sure they’re not all old white men who focus on serial killers.”

“They are.”

She smiled and walked over to her desk. I watched. Her white skirt swished as she walked, her Toms changing the colour of the carpet. I could hear the pen scratching.

“I don’t want to go.” I whispered. 

She looked at me, her blue eyes melting. 

“I don’t want to go.” 

She handed me the prescription. I took it. 

“I’ll be here, if you change your mind.”

“Promise?”

“Promise.” A single tear rolled down her cheek.

“Thank you.” 

She didn’t say anything. She just wrapped me up in her warm arms, and held me close as we both shook with tears. 

“I’ll finish the goodbye letter.” I said, pulling away.

“I’m excited to read it.” She replied, putting her hand on the doorknob. 

“It’s time, isn’t it?”

She nodded.

I gave the office one last look, one last time, and then I stepped into the hallway with a smile on my face and tears in my eyes, because I knew I was ready, because I knew it was time to move on. London was calling, and life was waiting. So goodbye for now Dr. S, and thank you, thank you for everything. I love you so much. 

Brownie Sundae

In honour of Father’s Day, here’s an essay I wrote a couple years ago about my dad’s death:

There were dead people in the letters. Birds’ nests braided, golden, in the hollow of the O and around the corners of the H, and the dead people walked through them, tiny at first, tiny as they slipped through the toothpick-thin cracks in the concrete, as they spun between the letters and out into the heavy air. That’s when they disappeared, dissolved, disintegrated. They became part of the bubblegum blue sky, the tissue paper clouds, and the grass–the parched, the yellow, the grass, the grass with its life all hacked and sucked away.

What was it like to die? Was it like getting your ears pierced? Just a pinch! Was it sweet like eating a brownie? Was it like jumping into Barton Springs in December?

The dirt was slippery, quite, and grainy, and dry. That’s because it hadn’t rained in ages. (I was fine with that. I mean, I didn’t want it to rain tomorrow. Rain would ruin the Keep Austin Weird parade.) Hey, that’s why–why the grass was dead.

“We’re near TCBY, right?” I asked, tired of standing on the dirt by the side of a busy road, surrounded by suffocated grass, looking at the lettering on the side of an ugly, grey building.

“I–” The grumbling of a passing car gobbled up the rest of the nameless  family friend’s sentence.

“My dad would let me have ice cream,” I crossed my arms defensively.

An old, silvery woman with skin like a wet paper bag had just peered out from behind the L.

“Are you sure you want ice cream?”

“Um, duh.” What kind of question was that?

We got in the car. The doors, as they shut, clicked like the trigger of a gun. “Here,” I took out my phone, my nine-year-old self’s prized possession, which looked rather like an enlarged green jellybean, “I’ll call my dad.” I said that like it was such an imposition. “He’d let me have ice cream.”

The phone rang. There was no answer. I tried again.

We weren’t moving; it wasn’t the 5:30 traffic; he hadn’t started the car. “I promise,” I whined, impatiently slamming my fingers onto the phone’s plastic buttons. “My dad takes me to TCBY every day.” That wasn’t entirely true. (We went almost everyday, but only when I had practiced violin for an hour and twenty minutes and only if we rode our bikes around the block and down the steep Far West hill to our destination.)

“Stop.” He said quietly; he sounded like his mouth was stuffed with cotton balls.

“Stop what?”

“Stop calling him.”

“Why?” He wasn’t going to get me the ice cream. I could feel it.

“He’s not going to pick up.”

The nameless family friend sounded so serious. It wasn’t a big deal. My dad was probably just brazenly taking the Band-Aid off his knee–why would he even need it? he just fell off a bike!–or signing the discharge papers. He’d meet us there. “He’d even pay you back.”

I heard a “fine,” a defeated, muffled “fine.” The red car turned on, and the engine spat golden-orange, glowing sparks. We drove away from the building, from the faces in the lettering, down the highway, and past a screeching ambulance. The dead people faded into red, and then into grey, then into white. They were just dead people, dead people in the letters, getting fainter, getting lighter, getting softer, as we got farther and farther from them.

It did not occur to me that at 6:53PM there would be crooked, yellow teeth, a mustache, and a white bicycle in the crevice on the letter P, bicycling, bicycling in circles, bicycling up and down. As we drove, the family friend and I, in the maroon car towards the swirls of frozen yogurt and the fountains of sprinkles, they–the corpses–looked down, placid, knowing, watching. They smiled; they smiled, because they knew, the dead people in the letters.

Wear It Beat It Day

Today 7 million people in the United Kingdom will fight their daily battles with cardiovascular disease. Today 435 people will lose that battle; today 110 of them will be under the age of 75. Today 530 people will go to the hospital with a heart attack; today 190 of those people will die. Today 657 people will have a stroke; today 109 of them won’t survive. Today 12 babies will be diagnosed with a congenital heart defect; today 1 of them won’t get to grow up. Today 82 out-of-hospital cardiac arrests will occur; today less than eight of them will live to see tomorrow. 

Today 34% of people in the United Kingdom will live with high blood pressure; today over half of them will continue to go without treatment. Today 6% of the population has diabetes; today that number does not include the estimated one million who remain undiagnosed. Today 27% of people in the United Kingdom will be obese; today 34% of them are overweight. Today 25% of people will exceed the national alcohol intake recommendations. Today 39% of people will not get adequate physical activity. Today 25% of people will not eat enough fruit and vegetables. Today 17% of people will smoke a cigarette; today smoking-induced cardiovascular complications will kill 55 people. 

Today you can do something about these numbers. Today you can maintain a healthy weight. Today you can quit smoking. Today you can get cardiovascular exercise. Today you can eat balanced diet. Today you can visit your doctor and get heart-checked. 

Today is Wear It Beat It Day. Today we wear red to raise awareness about heart disease. Today we stand in solidarity with those effected. Today we honor the lives lost and lived to and with cardiovascular disease. Today we donate to fund lifesaving research. Today we fight heart disease. 

Body in the Mirror

I see a body in the mirror. It has a small frame, a rectangular shape. Its feet are stars, and its ears stick out. Its long legs are locked straight, and it’s arms look like branches, flat by its sides. Long black hair falls down its shoulders, over its back, tapering to faintly outlined hips. It has a round face. The forehead is large. Trapezoidal eyebrows float above big, brown eyes, and a sharp nose bisects the oval. Circles hang under the eyes, and cheekbones float above hollow cavities, a little too close to the jaw-line.

Spindly and precarious, a neck collapses into soft, round shoulders. The shoulder-blades stick out, and you can see the grave where a collarbone used to be. The chest is flat, lined with the sketch of a rib cage, one that once was.

Under a green brassiere, breasts hang down. Arms fumble with it, snapping the clasp, slipping it off, diamonds as they do. Pink nipples sag, and stretch marks glint red and white, red and white in the nighttime light. 

The stomach crinkles, and there are snowdrifts, small muscles making snowdrifts. Hips curve outward, a frail pubic area melts into thick thighs, touching then not, not then touching. Knobby knees follow, and so do pointy calves. Feet dig into the floor, and veins run through them all, rivers and tributaries, tributaries and rivers, so blue under rice-paper skin. 

I see a body in the mirror. Yes, I see a body in the mirror, but it isn’t mine.

Pizza Hut

There was a Pizza Hut on my way back from dance. I used to walk past it almost every night. I’d press my face against the window and gaze at the cloud-like crusts, the buttery garlic bread, the golden oil glittering atop the cheese. I could smell the salt, the tiny granules dancing inside my nose, and I could taste the tomato sauce, the lightly sautéed veggies, the… “You can go to Pizza Hut when you weigh 42 kg.” I told myself, lurching away. “You can go to Pizza Hut when you weigh 42 kg.”

“You can go to Pizza Hut when you weigh 41 kg.” 

“You can go to Pizza Hut when you weigh 40 kg.” 

“You can go to Pizza Hut when you weigh 39 kg.”

The number kept getting lower and lower, and by the time I got to 38 kg, I finally realized I would not be going to Pizza Hut. I would never be thin enough, and if I ever was my metabolism would’ve slowed down too much to handle it. One bite of that cheesy, greasy pizza, and I’d gain back all the weight I’d worked so hard to lose. 

So I just kept walking. I shouldn’t even look at it, I decided, then I would go in, and I couldn’t have that. So I just kept walking. 

~~~

There’s a Pizza Hut on my way back from dance. I walk past it almost every night. I used to press my face against the window, and stare at the salad bar, the white bowls of crispy lettuce, the swirling spirals of the pasta, the red, ripe tomatoes. I used to stand outside and smell the food, and I used to imagine myself eating it, what it would taste like, what it would feel like sliding down my throat… 

“You can go to Pizza Hut when you weigh 42 kg.” I used to tell myself. I still hear those words in my head. I still see those words in my mind. I still feel those words in my brain. 

So I decide I’ll go someday. I should, shouldn’t I? It would be a crucial step in my recovery. I could even write a blog post about it! So I decide I’ll go someday.

~~~

There’s a Pizza Hut on my way back from dance. I’m walking past it right now. I look in the window, and I glance at the menu, the appetizers, the drinks, the mains, the desserts. I turn to my friends, and I nod, and I smile, and I open the door, and I put one foot in front of the other, and I take that step.

“You can go to Pizza Hut when you weigh 42 kg.” My eating disorder used to tell me. I can’t help but think about those words; I can’t help but remember that world. It was my life for a very long time, a very long time ago. 

But here I am at Pizza Hut, weighing a whole lot more than 42 kg, about to enjoy a veggie pizza with a side of fries. I never thought I’d get here, but here I am; here I am at Pizza Hut.

Happy Birthday!

Last year, I was taken to the hospital after I fainted on the way home from a final exam. I spent the day pulling tubes out of my arms. I watched the listless whitewashed walls and listened to them tell me to eat. I ignored their worried voices, shaking my head at the food they brought me, laughing when they told me I was going to die. It was just so funny: Me counting the seconds to death, me laying in a half-dead hospital bed. That was no way to celebrate a birthday, so I got up and left. It’s been a rough year since then, since I snuck out of that hospital on May 9th, 2016. I’ve had heart attack, dropped out of school, left my home, and technically died for three minutes. It’s been–without a doubt–the worst year ever, but somehow, I got through it; I gained thirty-nine pounds, graduated cardiac rehab, started a blog, and quite literally came back to life. I survived; against all odds, I survived, and that’s something worth celebrating.

So here I am, sitting in a Starbucks, drinking free hot chocolate and writing this post. I’ve got some research to wrap up at Senate House, and then I’m off for ice cream with my friends before dance this evening. There’s a ridiculous smile plastered across my face, and as I lick the whipped cream off my chin, I can’t help but shed a tear. It’s just so funny: How much I’ve lost, how much I’ve gained, how much I’ve learned, how much I’ve changed. It’s been one hell of a year (and one hellish year), but I’m so glad I stayed.